The Journal of Arthroplasty Vol. 20 No.

7 2005

Does Body Mass Index Affect The Early Outcome of

Primary Total Hip Arthroplasty?

Matthew Moran, MRCSEd, P. Walmsley, MRCSEd,

A. Gray, MRCS, and I.J. Brenkel, FRCS

Abstract: There is little evidence describing the influence of body mass index on the
outcome of total hip arthroplasty (THA). Eight hundred patients undergoing primary
cemented THA were followed for a minimum of 18 months. The Harris Hip Score
(HHS) and Short Form 36 were recorded preoperatively and at 6 and 18 months
postoperatively. In addition, other significant events were noted, namely death,
dislocation, reoperation, superficial and deep infection, and blood loss. Multiple
regression analysis was performed to identify whether body mass index (BMI) was
an independently significant predictor of the outcome of THA. No relationship was
seen between the BMI of an individual and the development of any of the
complications noted. The HHS was seen to increase dramatically postoperatively in
all patients. Body mass index did predict for a lower HHS at 6 and 18 months. This
effect was small when compared with the overall improvements in these scores.
There was no influence on the Short Form 36 component scores. On the basis of this
study, we can find no justification for withholding THA solely on the grounds of BMI.
Key words: body mass index, total hip arthroplasty, Harris Hip Score.
n 2005 Elsevier Inc. All rights reserved.

Total hip arthroplasty (THA) provides long-lasting
improvement in quality of life and reduction in
pain for patients with disabling arthritis. However,
there are groups of patients that have been shown
to have outcomes that are poorer than the general
population. A poorer outcome may be affected by
the underlying diagnosis, for example, femoral
neck fracture [1]; by the choice of implant, for
example, the Capital THA [2]; or by the surgeon,
for example, infrequently performed THA [3].
From the Department of Orthopaedic Surgery, Queen Margaret
Hospital, Dunfermline, Fife, UK.
Submitted November 18, 2003; accepted February 3, 2005.
No benefits or funds were received in support of the study.
Reprint requests: Matthew Moran, MRCSEd, 19 Plewlands
Gardens, EH10 5JS Edinburgh, UK.
n 2005 Elsevier Inc. All rights reserved.
0883-5403/05/1906-0004$30.00/0
doi:10.1016/j.arth.2005.02.008
There are concerns that an increasing body mass
index (BMI) negatively impacts on the outcome
of THA, and surgeons may decline to operate
on the obese for fear of the complications that
may follow. Possible areas of increased complica-
tions include increased length of operative time
[4,5], venous thromboembolism [6], superficial
and deep wound infection [7], increased blood loss
[8,9], and aseptic loosening due to increased
loading through the THA.
Despite the theoretical increased rate of compli-
cations, there is evidence to show that the symp-
tomatic relief after THA is as effective in the obese as
in thinner patients [10,11]. In 2000, the UK National
Audit Office criticized orthopedic surgeons for the
use of bvarying criteria for weight above which they
may not operateQ [12]. It is important that decisions
about the suitability of patients for surgery are made
on good evidence. We set out to examine the early
complication rate in obese patients after THA.

866
 Does Body Mass Index Affect The Early Outcome of Primary THA? ! Moran et al 867
Methods
Patients
Eight hundred consecutive patients undergoing
Charnley primary THA (De Puy International,
Leeds, UK) were investigated prospectively. The
patients were under the care of 6 consultant
orthopedic surgeons at a single hospital. The joint
arthroplasties were carried out between January
1998 and November 2000. A standard anterolateral
approach to the hip was used by all surgeons. Data
from the patients were collected by a specialist
nurse and stored on a local database.
The following events were recorded: length of
stay in the hospital, death, dislocation, reoperation,
superficial and deep wound infection, blood loss,
and transfusion requirement. Superficial wound
infection was diagnosed in the presence of dis-
charge from the surgical wound or spreading
cellulitis and a positive microbiological culture of
a microorganism known to be implicated in causing
wound infection. Deep infection was suspected on
clinical and radiological grounds but only diag-
nosed after the growth of putative microorganisms
from specimens taken at reoperation. Blood loss
was calculated from perioperative losses (suction
and swabs) plus postoperative drainage.
Concomitant medical problems were recorded
under the headings: smoker, cancer, atherosclero-
sis, cardiac, diabetes mellitus, osteoporosis, and
thromboembolism.
Outcome Measures
The Harris Hip Score (HHS) and Short Form 36
(SF-36) were the primary outcome measures used
[13,14]. The HHS combines scores for pain, func-
tion, activities, absence of deformity, and range of
motion to produce an overall score out of 100
(0, bad; 100, good). The score is mostly determined
by feedback from the patient and weighted strongly
toward pain and function. It has been shown to
be a reliable indicator of patient function and pain
before and after THA [15]. The SF-36 is a widely
used measure of patient health that is not specific
to one disease. It is a good measure of patient
symptoms after THA [16]. Both scores were
completed 7 days preoperatively as well as 6 and
18 months postoperatively.
Body mass index was taken as a marker of
obesity. It is calculated from the weight (kilograms)
divided by the square of the height (meters). The
BMI is widely recognized as a tool for the simple
calculation of obesity. It corrects the weight of the
patient for their height. A score is generated with
20 to 24.9 kg/m2 reflecting ideal weight, 25 to
29.9 kg/m2 reflecting overweight, 30 to 39.9 kg/m2
reflecting obesity, and 40 kg/m2 or greater reflect-
ing morbid obesity.
Statistics
The SPSSv9.0 (SPSS Inc, Chicago, Ill) computer
package was used to analyze results.
The paired Student t test was used to detect
changes in the HHS before and after surgery.
Univariate analysis was performed using v 2 tests,
2-sample t tests, or Pearson’s correlation coefficient
to identify significant predictors of the measured
outcomes. The predictors were operating surgeon,
age, sex, side of surgery, length of stay in hospital,
concomitant medical problems (see above), blood
loss, transfused units of blood, and preoperative
HHS. The outcomes were reoperation, death,
dislocation, deep and superficial infection, and
HHS. Once possibly significant predictors of out-
come had been identified by this method, stepwise
multiple regression analysis was carried out to
identify any predictors that would independently
alter outcome. Multiple logistic regression was
performed for binary outcomes (eg, death) and
multiple regression linear analysis for continuous
variables (eg, HHS).
Results
Eight hundred total hip arthroplasties were
carried out in 759 patients. Sixty-one percent were
female and 39% male. Four hundred fifty-nine
THAs were left sided. The mean age was 68 years.
Of the 800 THA episodes, all completed a preoper-
ative HHS and SF-36. Seven hundred seventy-four
completed an HHS/SF-36 at 6 months and 687 com-
pleted the scores at 18 months. The mean BMI was
350
300
Number of patients
250
200
150
100
50
0
<20 20-24.9 25-29.9 30-39.9 40+
Body Mass Index
Fig. 1. Distribution of patients by obesity category.
868 The Journal of Arthroplasty Vol. 20 No. 7 October 2005
27.8 kg/m2 (range, 17-49) with a standard devia-
tion of 5 (Fig. 1). There was no difference in the
BMI of patients defaulting to follow-up and those
who completed follow-up ( P = .32). On average,
0.7 units of blood were transfused and mean blood
loss was 537 mL (SD, 296 mL). The mean length of
stay was 10 days.
Thirty-three patients had died by the 18-month
follow-up (39 hips). There had been 13 dislocations
(at an average of 15 weeks). Fifteen patients
underwent a further operation (not including
reduction of a dislocated joint). Three revision
operations, 11 debridements, and 1 posterior lip
augment were carried out within the first 18 months.
Seven deep infections and 56 superficial wound
infections had occurred by 18 months.
The mean preoperative HHS was 42. This im-
proved to 81 at 6 months and 85 at 18 months
postoperatively. There was a significant improve-
ment in the HHS scores at 6 and 18 months when
compared with the preoperative score ( P b .0001).
Univariate analysis suggested that BMI might
predict for increased rates of superficial infection
and a lower HHS at 6 and 18 months postopera-
tively (all P b .05). However, once multiple logistic
regression was carried out, BMI was not found to
be a significant independent predictor of superficial
wound infection.
When multiple regression analysis was per-
formed for the HHS at 6 and 18 months, taking
into account other significant predictors, BMI was
still found to be significant ( P = .02 at 6 months and
P b .001 at 18 months). To calculate the individual
effect a change in BMI might have on HHS, the
HHS 6 HHS 18
30
25
% variance explained
20
15
10
5
0 loss in obese patients when compared to those
Baseline Length stay Comorbidity
HHS
Fig. 2. The relative contributions (percentage of variance
explained) of predictors to the HHS at 6 and 18 months.
Comorbidity indicates coronary and thromboembolism;
Hb, hemoglobin; HHS 6, Harris Hip Score at 6 months;
HHS 18, Harris Hip Score at 18 months.
multiple regression coefficient b was noted. At
6 months, b = .25 (95% confidence intervals
[CIs], .05 to .45), and at 18 months, b = .35
(95% CIs, .15 to .55). That is, for every 1 point
increase in BMI, the HHS dropped on average by
0.25 or 0.35. The other predictors with a significant
individual influence on the postoperative HHS were
length of stay, previous thromboembolism or coro-
nary heart disease, drop in hemoglobin at 24 hours,
and preoperative HHS. By far, the most significant
of these is the preoperative HHS (see Fig. 2).
Body mass index was not a significant predictor
for any of the SF-36 component scores.
Discussion
The HHS improved considerably after surgery.
The hip score is weighted toward the patient’s
assessment of pain, function, and activity (91 of
100 points), with lesser emphasis on surgeon-
determined measures such as range of motion
and absence of deformity (9 of 100). Ultimately,
the patients’ view on the outcome of surgery is
probably the most important, and the HHS is a good
measure of patient symptoms.
Body mass index independently predicted for
a lower HHS at 6 and 18 months. However, its
individual effect, whereas significant statistically,
was small. If we take a change in BMI of 20 points
(the difference between being underweight and
morbidly obese), we estimate that it will only
produce on average a lowering in the HHS of 5.0 at
6 months and 7.0 at 18 months. These changes are
small given that the mean improvement in the HHS
at 18 months is 43. None of the 9 component scores
of the SF-36 were predicted by BMI.
We saw no relationship between BMI and early
failure of THA. Although the obese may put
increased loads through their joint arthroplasty,
there is evidence that the more obese a patient, the
less active they are. Hence, the increased weight is
balanced by decreased cycles of loading [17].
In a paper comparing 41 obese and 125 nonobese
patients, Soballe et al [9] noted increased blood loss
in the obese group. In a series of 80 patients,
Bowditch and Vilar [8] also noted increased blood
Drop Hb BMI of ideal weight. Multiple regression analysis is a
sophisticated tool that allows for the correction of
other variables in assessing the individual influence
of BMI. Even with the large numbers in our study,
once other factors such as comorbidity are taken into
account, we did not find that BMI per se increased
measured blood loss or transfusion requirement.
 Does Body Mass Index Affect The Early Outcome of Primary THA? ! Moran et al 869
It is likely that the comparison of obese and non-
obese without factoring in confounding data over-
simplifies the true state of affairs.
We did not divide the patients into groups
based on BMI, as these divisions of a continuous
variable would be arbitrary. One of the strengths
of this paper is the use of regression analysis to
identify independently significant predictors. For
example, in our initial univariate analysis, an
association between BMI and infection was sus-
pected. However, an increased BMI is associated
with an altered incidence of other conditions,
such as diabetes mellitus. It would have been erro-
neous to draw the conclusion that obesity is
responsible for increased rates of infection, with-
out allowing for the fact that BMI is also
associated with the incidence of diabetes. Regres-
sion analysis allows us to separate out diabetes
and BMI and test the effect of each on the
incidence of infection. There were only 9 patients
with a BMI more than 40 kg/m2. This is in
keeping with other studies that have investigated
the effect of BMI on the outcome of lower limb
arthroplasty [18]. We did not study enough
patients with a BMI more than 40 kg/m2 to make
any definite conclusions about this group.
Although BMI does predict for a slightly lower
HHS and SF-36, there is no association with other
outcome measures used. Even with a large cohort,
complications after primary THA are rare. For the
commonest complication, superficial wound infec-
tion, there was a 3-fold range for the CI for the odds
ratio for obese (BMI more than 30 kg/m2) relative
to nonobese patients. This may indicate that the
power of the study is too low to give a precise
estimate of the effect of BMI on the risk of rare
complications. The effect on the HHS is small and
we do not feel it is large enough to warrant
withholding THA from patients solely on the
grounds of body mass.
Our results reflect postoperative complications
and early outcome of THA. We continue to follow
these patients to ascertain the medium and long-
term effects of body mass.
Acknowledgments
We thank Dr Rob Elton for statistical support.
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